Provider Demographics
NPI:1609934231
Name:HOOSHANGI, MITRA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MITRA
Middle Name:
Last Name:HOOSHANGI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 GALLOWS RD STE D
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3963
Mailing Address - Country:US
Mailing Address - Phone:703-893-7900
Mailing Address - Fax:703-893-7989
Practice Address - Street 1:2112 GALLOWS RD STE D
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3963
Practice Address - Country:US
Practice Address - Phone:703-893-7900
Practice Address - Fax:703-893-7989
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA78501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice